While the issue of Electronic Medical Records and physicians seems a little off base for an EMS blog, the reality is that their use and adoption is occuring throughout all levels of healthcare. This includes the prehospital arena and intrafacility transport systems. Insurance information capture is now stressed with most ambulance systems, both public and private. The concerns and thoughts expressed by the below reposted blog by Dr Palestrant, therefore, I believe address the 911 community as well.

An added concern that I have as an Emergency Medicine physician is that most of the prehospital documentation systems don't integrate with the EMRs established in the Emergency Departments. By and large, the EMRs which have been adopted reflect administrative decisions without consideration of the care provider's/Emergency Department's needs. Specifically, it is absolutely obsured that charts produced via a 911 squad don't automatically populate and integrate with any giving receiving hospital's Emergency Department record. Often hours to days pass without a hardcopy arriving (if ever provided). What good does this do for the patient? Intrafacility transport services are forced to waste time extracting needed information from a hospitals system and hand keying it into their charts, mostly extracting demographics for billing purposes, while a patient awaits an airlift to a nearby cath lab or stroke center. Where is the conductor who is orchestrating this adoption of Electronic Records?

The lack of harmony and consistency with EMRs, both facility based and prehospital is addressed in Dr Palestrant's post.

The direct link to his post is here: http://par8o.com/wordpress/why-emr-is-a-four-letter-word-to-most-doctors/

The full and text follows below:

Don’t get me wrong, EMRs (Electronic Medical Records) are inevitable. Over the long-run they are almost certainly good for physicians, patients and the healthcare industry.

However, their origin and the ulterior motives currently driving their adoption is sowing the seeds of their failure. First, what is ACTUALLY happening out there? The most recent CDC data would seem to be encouraging for EMR adoption (http://1.usa.gov/vu8wiy), with EMR use (finally) passing 50%.

Too bad there is more to the story.

If you look at adoption rates for so called “fully functional EMRs” (http://bit.ly/uUQ3FV), the adoption rate remains in the low teens (full data for 2011 is not yet available). So why is there an almost 4-fold discrepancy between “any EMR” and “fully functional EMR”? If EMRs are so great, why does the government have to essentially “bribe” physicians to adopt them through incentives such as the meaningful use incentive program (http://go.cms.gov/97BFXJ)? Why is this so important to them that they didn’t even wait for the healthcare affordability act to implement this “incentive”? (They put it in the stimulus package after Obama had only been in office a few months.)

The 50% adoption rates seen in the first link reflect the presence of ANY type of an EMR-like technology. While it is a great headline for sure, the second link shows that this is an overly broad declaration. When we look at “fully functional systems,” meaning they are being used for a full work-flow solution, we get numbers in the low teens instead. (When you subtract out unique situations such as Kaiser, the VA, and a few large independent doctor networks, I suspect the actual number is much lower.)

One reason that incentives and threats of decreased payment are necessary for EMR adoption is that the industry and physicians have known for years that EMRs do not improve productivity and that it is highly questionable that EMRs lead to better patient outcomes. So why is all this taxpayer debt being accrued by throwing borrowed money at the healthcare industry to drive EMR adoption, if the end users are so disenchanted? As Jonathan Bush, the Founder-CEO of AthenaHealth (a major EMR supplier) famously said, “It’s healthcare information technology’s version of cash-for-clunkers”(http://bit.ly/9ZgUa7), and,

Because it is actually all about control.

The goal of EMRs is to wrestle control of healthcare away from the doctor-patient relationship into the hands of third parties who can then implement their policies….by simply removing a button or an option in the EMR. If you can’t select a particular treatment option, for all intents and purposes the option doesn’t exist or the red tape to choose it is so painful that there is little incentive to “fight the system.”

For patients, this means that they will only be able to consume the healthcare that they “qualify” for or be forced to find another way to obtain the care that they want and need. It is the second outcome, see previous post (Benjamin Franklin, Lightning & Ex-Communication) that is the most intriguing, because as “shoppers,” patients will want to be informed and have choices as they take on more responsibility for the cost and quality of their own care. This approach works very well with Health Savings Accounts, which were conveniently deemphasized in the healthcare reform effort. Like the lightning going to ground, this is the inevitable future for healthcare in this country (assuming the other alternative, an acceleration to a single payor system does not occur first).

For physicians…well, it isn’t hard to figure out where this is all heading. EMRs are quickly becoming the instrument by which we are controlled and managed. As an example, many organizations are already starting to restrict diagnostic testing and therapies via EMR.

What’s next? Patient referrals? It will be the final step in subjugating physicians.

So why is genuine EMR adoption struggling so much? After all, one may argue that the accessibility of instant data that technology now enables is the greatest single advance in patient care so far this century. With so much money being thrown at the problem, one might expect a much greater adoption. Why hasn’t it played out in a much more positive way?

This comes back to the origin and ulterior motives of EMRs. First, EMRs have been largely a top down effort. Rather than working with physicians to design the technologies and drive adoption, the experience (and almost universally the perception) is that the technology has been thrust upon physicians by administrators. Compounding this is the unintended consequences of the meaningful use government incentives (or cash-for-clunkers program to use Jonathan Bush’s, more colorful language). Having left the guidelines vague and largely written by a small group of industry insiders, most products have become a Tower of Babel with atrocious user interfaces and user experiences that….well, I don’t blame my fellow physicians for not wanting to use them. In addition to being expensive, they are complex, inefficient, and do not make physicians or their staff more productive.

Widespread adoption of an EMR (or multiple compatible EMRs) that is intuitive and easy to use, that empowers the end user and patients, and that actually helps to make the healthcare system more efficient would be a good thing for doctors, patients, and the industry. However, unless we recognize what the ultimate goals are and better involve the people most critical to their effective use (physicians), I believe Jonathan’s prediction will be true and cash-for-clunkers applied to the healthcare sector will turn out about as successful as that other government program…TARP.

I have a very good friend who is a nurse who recenty admitted to me that the reason s/he "dropped off the face of the Earth," was s/he had an addiction problem. This person is on the road to recovery and offerred to write about what occurred. Interestingly, over the years, I have come across many healthcare workers in EMS with addictive problems. Some with alcohol, some with other substances. Regardless – please read and share comments. This clearly is an important topic to discuss

Creating and Maintaining Drug Addictions in the EMS/ED Setting

Addiction and associated drug-seeking behaviors have reached, to use a cliché, epidemic proportions. The sad thing is that patient satisfaction surveys, patient “rights”, and lack of support from administrators when confronting behaviors has contributed to this problem far more than the addicts themselves. In days gone past, we had our heroin junkies, our pot smokers, and our valium-grandmas; these patients we could see coming from a mile away. Today’s addicts come from all walks/occupations, all age groups, and are less easily identified than in the past. They can be lawyers, hamburger-flippers, homemakers, mechanics, car salesmen; or in my case, an ER nurse.

No one was more surprised than I was the day I entered rehab for opioid dependence. An experienced ED nurse of 15 years, with a great reputation as a leader, teacher, mentor; I was a junkie. Popping or snorting oxycodone or shooting up dilaudid was my daily routine, in between taking care of patients. But as with all addicts, I could rationalize, minimize, or bullshit my was out of any situation. Until I hit the bottom. I tell this not for sympathy, understanding, or shock value; but to underscore my understanding of these addicts which I always hated taking care of. After all, they were taking up my time, lying to me and expecting be to believe their pain scores, and generally being a waste of space.

Our role in the problem is creating the addict, maintaining the addict, then condemning the addict. First we create them. Unlike the days of gateway drugs leading to heroin, today we prescribe Percocet and oxycontin for pain. Legitimate drugs for legitimate reasons, we keep giving these meds and keep writing the refills… Then one day the patient tries to cut down or stop and get “dope-sick”, a horrible withdraw constellation of pain, anxiety, cramps, shakes, nausea, and feeling of impending doom. All these go away as soon as another “oxy 30” hits the GI tract.

When I was in rehab, I met many addicts, some as young as 19, who were addicted to narcotics secondary to a back injury, a surgery, or other legitimate illness/injury. It would be impossible for me to count the number of prescriptions for percocet, vicodin, oxycontin that I handed over for a sprained ankle, broken finger, or even a peritonsilar abscess. Imagine how many more are given upon discharge from an inpatient setting after injury or surgery. Oxycontin is so powerful and addictive that one 21 year old addict that I spoke with turned to heroin after his doctor cut him off from oxycontin, if given the choice between IV heroin or snorting an oxy 30 would take the oxy every time. Heroin was what he turned to when he couldn’t get his drug of choice. Imagine that; heroin is second best to a pill.

The second problem is maintaining the addict. We’ve all gotten calls for patients with intractable back pain who can’t drive to the hospital, after they’ve run out of their narcotics. So we roll our eyes, load them on the litter, and dump “another drug-seeker” into the ED. Then the ED doc, who knows that his paycheck is based, at least in part, on his “patient satisfaction scores, is torn between giving a shot of dilaudid and a script for “enough narcotics until you can see your doc”, and dealing with a negative patient survey than translates to less dollars in his/her paycheck. Add to this a crazy busy night in the ED, overloaded, and its often just easier to give them what they want and get them out of the ED “so we can take care of real patients”.

If we call the patients on their drug-seeking behavior, then we’re called to the carpet from a director, a manager, or a charge nurse who quotes something from an ancient text; “Pain is subjective, it’s whatever the patient says it is..”. After all, the ED/EMS setting is a business, and “we have to keep the customers happy”. I’m guilty of this myself. Many times I’ve told a doc “Look, this morons is just drug-seeking, but causing all kinds of ruckus. He’s tying up two of my nurses, the tech, and three security guards, and I just got a call from the ‘patient advocate’. And there’s thirty patients in the waiting room to come back. Can you just write for whatever he wants so I can empty the bed and get back to the patients who are really sick? Please…”

Then we condemn them. I’m as guilty of this as anyone, perhaps more so. Addiction is a disease, right? What a load of crap! It’s just a lack of willpower or some loser who wants a free high. Or they come in to get into detox and rehab, perhaps legitimately wanting help or just making their parole office or family happy, and we let them sit for hours, in pain, while waiting for social services to find a bed for them at some rehab facility. To keep them comfortable, we “might” give them 1mg PO ativan and some zofran. Then we wonder, after sitting for eight hours in withdraw, the sign out AMA while yelling “you people don’t want to do anything for me”. I sat in the intake office at a detox for five hours while waiting for insurance to clear, in full blown withdraw, and believe me it was not fun. Only the thought of permanently losing my nursing license and fear of my wife kept me there.

Why don’t we treat the withdraw while waiting for placement? If someone is withdrawing from narcotics, who are we not giving them narcotics? Detox centers use a tapering program of Subutex to bring patients down over a period of three to five days. Patients are using upwards of 240mg of oxycontin a day or 4-10 bags of heroin, yet we thing nothing of giving them a little ativan and zofran, thinking that will keep them quiet until we can get them placed. Are we withholding the narcotics to punish them? Would we withhold D50 from a diabetic whose blood sugar was 20? Are we not withholding medical treatment?

So what is the answer? If I knew that, I’d be heading up the presidential council on drug addiction, rather than going to Cocaine, narcotics, and alcoholics anonymous. Perhaps, rather than condemning the addict, we need to look at our own behaviors and attitudes towards them. We created many of them, then we crush them and withhold care. Perhaps we need to worry less about patient satisfaction surveys driving our standards of practice, and more about the patient. While its true that “if we don’t give them what they want, they’ll just go somewhere else”, that can’t be our guiding principle. If a patient wanted another medication, say a cardiac med that they heard was good, would we give it to keep the patient satisfied?

Somehow, and I’m still trying to figure out how, I crossed the line from social drinker and occasional Percocet user for back pain to a full-time junkie, shooting up between patients in the bathroom. Yet still able to provide care for the most critically ill patient. Only through the grace of God did I not harm anyone other than myself. I’ve reached the bottom of a hell that I wouldn’t wish on anyone (other than a nursing administrator or two). But if there is a good side to this addiction of mine, I’m becoming a better person than I was before; less selfish, self-centered, grandiose and ill-tempered. And when the state decides it’s time for me to begin practicing as an ED nurse again, I’ll have a very different perspective for this unique group of patients who can be very challenging to care for. Perhaps God made me an addict to allow me to care for other addicts. Stranger things have happened.

I had the wonderful pleasure this Wednesday and Thursday to attend the Neuroscience Conference hosted by Capital Health Center at the Borgata, in Atlantic City, New Jersey. One of the speakers was Mr. David Knowlton. Mr Knowlton is the President and CEO of the New Jersey Health Care Quality Institute. He is a fantastic speaker who is driven to improve health care delivery for the state of New Jersey.

A major element of his talk had to do with the recently passed Health Care Reform Bill. It we be affecting all of us over the next couple of years. He showed a video, whose link is provided below, which explains this bill. While not an expected topic for publication in a blog centering around EMS, I urge you to watch.

]]>http://www.theemsblog.com/2011/05/07/health-care-reform-hits-mainstreet/feed/0A Tale of Two, Two Tiershttp://www.theemsblog.com/2011/04/27/a-tale-of-two-two-tiers/
http://www.theemsblog.com/2011/04/27/a-tale-of-two-two-tiers/#commentsThu, 28 Apr 2011 02:41:09 +0000http://theemsblog.com/?p=289 Disclaimer: I appologize for the format of the text as this is one of my first blog entires with this interface, and for some reason it and Word didn't want to play nicely. I tried to fix it up best I can. Future posts will not have this problem.

It’s interesting that Dr. Barnett picked a topic in the previous blog that is so near and dear to my heart. Rather than post a comment, I decided to create a new entry, because it’s going to be lengthy in nature, and I would like to see separate comments and feedback. Why, might you ask? Well, I’m a true believer in EMS, and in the ability of providers to bring quality basic and advanced pre-hospital care to the public.

Throughout the fifty states and assorted territories, each individual EMS system needs to adapt to specific needs of the community. It is not a “one size fits all” system. Some states have system wide mandates whereas others leave it to each individual organization or municipality to decide on how they are going to operate their EMS system. All must operate within their regulations, but some allow for more self rule than others. With this, I am going to go a little more into detail on the “chase” system in New Jersey and how we differ and compare to other systems that are run through the country.

I believe our system is “unique”, and, dare I say BETTER in some ways, while antiquated in others. To understand EMS in New Jersey, we need to look way back in the past to when the EMS system in New Jersey was conceived. Since we are focusing on southern New Jersey (which for those not from this area, is COMPLETELY different from the north), I am going to use references and examples from this region to simplify things. The Office of Emergency Services (OEMS) was created in 1967, and was charged with the task of creating standards as well as regulations regarding pre-hospital care. At this time, calling pre-hospital care basic life support was a stretch at most. Certifications evolved, and we went from the 5 points certification, to EMT. Now, we must not forget that OEMS was not the only “organization” that had an interest in EMS in New Jersey at this time. Back then, EMS was run completely by volunteers that would pick up the ambulance and race to the call from home when the air siren blasted, or the old Plextron would alert. The New Jersey First Aid Council (NJFAC) , which even today exists as a private organization, was a place where volunteer ambulance squads could join to share ideas, support each other, and come together to lobby for a specific cause: volunteer EMS in the state. Back then, EMS was run 100% by volunteers.

Things, however, began to change. Up to this point, there was NO ALS in the state. I’m a little rusty on specific dates, but ALS didn’t evolve in NJ until the mid to late 1970’s; do we all remember “Emergency!”? New Jersey’s Department of Health wrote regulations which allowed for advanced pre-hospital care, but it was set up with a rather unique frame work. ALS could ONLY be provided through a hospital system, not by local EMS agencies. Also, in order to provide ALS care to a specific area, a hospital system that was interested in providing these services had to submit a formal request to OEMS in order to be awarded a Certificate of Need (CN). This CN would authorize a hospital system to provide ALS care within a specific geographical region, usually one or more counties. In the southern most counties, Camden, Burlington, Gloucester, Cumberland, Salem, Atlantic and Cape May, there were three main sources of ALS care, provided by three hospital systems: West Jersey, Underwood and Burlington Memorial. This CN system still exists to this day. A CN may be taken away and re-awarded if it is proven by a challenging agency that their area is being underserved by the current provider. Regulations that governed ALS care were written so that a two tiered system was created, which would allow for local volunteer ambulances to transport the patient, while the ALS unit would intercept the ambulance if advanced care was needed. There were wivers created which allowed for some systems, particularly up north, such a UMDNJ and Jersey City, as well as a few others, to provide ALS transport-capable ambulances. But they were the exception.

The MAIN reason a chase system was created was due to the local volunteer squads as well as the NJFAC. They didn’t want “outside people” to come in, transport “their” patients to the hospital, and illegitimize their existences. These volunteer organizations felt extremely threatened, and lobbied to the state so that they could maintain their local control, while allowing ALS intercept vehicles to come into the mix if needed. Added to this was a lack of ALS providers, as well as long transport distances which didn’t allow for paramedics to accompany every patient to the hospital.

Fast forward to today. We now have more ALS units (or less depending on where you live), more advanced scopes of practice, as well as more aggressive protocols. Some areas fared better than others financially, and those that were able to keep their heads above water, expanded their services and took over those that weren’t able to compete. In the beginning, ALS care was very profitable. Even though the volunteer squads wouldn’t charge for services, the hospitals would. All was well and dandy up to the point that Medicare started to reform its billing regulations.

Now keep in mind, New Jersey is NOT the only state that runs a completely tiered ALS system. WHAT!? Yes, it’s true. Some might call shenanigans on this, but it’s true. Our neighbor to the south, Delaware, has the EXACT same system that we do. They run a regionally based ALS system, chase vehicles with two paramedics that would intercept a BLS ambulance to provide ALS care. The main difference between the two states is that rather than being mandated to be hospital based such as we are, Delaware ALS is completely run by county governments. Granted, Delaware only has three counties, but it’s still a regionally based, tiered ALS system with extremely high quality of care, and run with great efficiency. Not to mention their volunteer and paid BLS agencies are all held to the same standard. (Can’t say the same about NJ!) There’s a reason I bring Delaware into the mix. You’ll see in a bit.

Medicare reformed its billing practices, and stated that only one agency is allowed to bill for services. Now, these ALS agencies have to contract with local squads, in order to bill for services through them. For example, let’s say an ALS ride to the hospital would cost $1,000, but the BLS agency bills for services which costs $500. The ALS agency has to submit their bill through the BLS agency, and spilt the difference in cost. So now the ALS and BLS agency both get $500. This is not very profitable if you have a low call volume. If the BLS agency doesn’t bill for services, then the ALS agency can send the bill directly to the insurance company, and get the full amount without having to share anything. Why do I bring this up? Because with this system in place, hospitals were unable to support their ALS services, and many were gobbled up by larger systems. My point is that hospitals aren’t able to maintain ALS coverage due to expanding populations without losing profitability, since they would have to staff more units, without being reimbursed their full amount to break even.

New Jersey brags that the state is 100% ALS covered, but what they fail to tell you is that it’s not 100%, 100% of the time. All too often, citizens go without ALS care, because there are no ALS units available. On a positive side, I feel that the tiered system is the way we should provide services in this state; however, I feel that ALS coverage needs to be expanded so that there are fewer gaps in coverage due to increased demand. The consensus on response times is that you should have BLS level care within 8 minutes or less, 90% of the time, and ALS care within 12 minutes or less, 90% of the time. While there are no regulations or laws that state this, it stands as a general consensus throughout the country. Now, working as a paramedic in New Jersey, I can say that the agency I work for is able to meet the 12 minute mark, 90% of the time. I can’t say the same, however, for BLS. There are countless times where I have sat on location, waiting for an ambulance for 20, 30, even 40 minutes at a time. Unacceptable. Many would argue that if paramedics were staffed in ambulances, we wouldn’t have this problem. True, but if agencies were regulated and mandated to meet minimum response time criteria, we wouldn’t even have this discussion. But that’s a different blog….

Still, one asks, why a tiered system? Simple; all one has to do is compare the amount of sick people, critical skills that are needed, and the amount of providers there are to provide these advanced interventions. Let me bring this more into perspective. Only about 3 – 5% of 9-1-1 calls for medical emergencies are actually life threatening in nature. Wouldn’t it make sense to have a proportional amount of people that can treat life threatening situations to the demand that actually exists? It doesn’t make sense to have a paramedic on every ambulance. Here’s another example. Let’s say that there are 1,000 highly invasive skills that are going to be performed within one year. If we had more ALS providers, say 26,000(roughly the amount of EMT’s in NJ), the chance that a good majority would encounter one of those 1,000 skills is highly unlikely. Now, let’s say we have 1,700 ALS providers (roughly the amount of paramedics in NJ). The likelihood that they are going to encounter one of these skills increases dramatically. Because we have a higher exposure to only extremely sick and critical patients, we are able to maintain our skills and a much higher clinical standard.

As a paramedic in New Jersey, I do notr respond to every broken bone, stubbed toe, cough, cold and tooth ache. We also have lower staff injury rates due to the fact that we don’t typically operate stretchers or other carrying equipment, and we are able to keep highly experienced medics because they are able to work longer due to lack of injury. I get sent to only life threatening emergencies when deemed appropriate. Everything else warrants only a BLS response. If BLS arrives on location and judges that we are required, they request our services, and we arrive on location typically within the 12 minute window. Here’s another interesting perspective. Some people actually come to work in NJ as paramedics from other states with single level response systems, in order to maintain their ALS skills. In their previous systems, they get sent to more basic, non life threatening calls, and have a lack of exposure to highly invasive procedures. How comfortable would you feel if you or your family member was being treated by such a medic? Would you want a medic that only does 1 or 2 intubations a year intubating you? Or would you want someone that quite literally may do several a week? It’s a no-brainer. Because we have such a high exposure, we are able to perform much more aggressive and invasive procedures. Remember I mentioned Delaware way back? That’s because they have the same tiered system we do with similar competencies and skills. And you know what, we have comparable success rates in high risk, low frequency procedures. Both New Jersey and Delaware prove that a tiered system works where appropriately applicable. Over-saturation of ALS providers is unnecessary; we must not have our skills be watered down. We merely need to have enough ALS providers to provide complete coverage within twelve minutes, ninety percent of the time, to calls where we are specifically required.

As for the legislation that is working its way through the Senate at this time, it would allow for a much needed overhaul of the system. Yes, there were provisions that were removed because of the lobbying from the NJFAC, but those things can be tackled at a later point in time. Personally, I don’t care about the training fund. Leave it for the volunteers. I paid my way through paramedic school, as well as additional certifications and higher education and certainly don’t miss the training fund. As for the two EMT standard, that’s ok as well. It’s better than NO EMT at all which seems to be the status quo for volunteer squads. As of right now, only BLS services that are licensed by OEMS are required to have two EMTs. Those that are not licensed do not have to have ANY EMTs. And no, as of today, there is no law or regulation that requires a BLS agency in the State of New Jersey to be licensed by OEMS. They basically regulate themselves, and do as they please. This piece of legislation would thankfully change that. In regards to EMT education, right now the Department of Health is revamping the way in which EMTs are trained in NJ, including the amount of classroom time and clinical hours required for testing. I agree with many of the responses to the previous post, that education standards need to increase, as well as minimum number of exposure hours to field and clinical settings. This too will get a future blog.

I found the comments regarding emergent mode of transport to a receiving hospital rather amusing. Personally, I only transport to the hospital with lights and sirens about 5 – 10% of the time. Unless the patient is next to death’s door, or needed to be in the hospital “yesterday”, they get no lights. With that, I believe BLS transport should ONLY be no lights or sirens, unless the patient deteriorates, or there is an immediate threat to the crew due to a combative patient, for which you should have a police officer present anyway. I once told an EMT that was transporting us to the hospital to use no lights and sirens. Her response “We don’t do that. It’s our policy, all patients get lights and sirens.” And so I replied “Too bad, no lights.” I’m not endangering my life for a stable patient, whom I can easily manage, by going lights and sirens for no reason at all. My agency encourages this position as well. Ok, this was long enough. I hope I was able to enlighten a few people about our lovely system (note the sarcasm), the pros, the cons, and the direction that our state is headed.

I had missed dinner and was heading in for my first of three night shifts. I made excellent time on the highway, and pulled into a local strip mall just several blocks from the hospital to grab a bite to eat before tackling my shift. Off along the curb a quarter mile back along the state highway was a local ambulance. The lights were flashing, the doors open, with a paramedic chase truck having clearly stopped the vehicle to assist with a patient in the rear. Where the ambulance was stopped is literally less than one mile to the Emergency Department entrance. Expecting the paramedic to have climbed aboard of the ambulance and to be off in moments, I entered the fast food establishment, grabbed my sandwich and soda and sat down to eat. Fifteen minutes later I exited and the ambulance was still sitting there. With New Jersey Highways being the way they are, the only way to assist would be to drive another half mile down the road, find a jug handle, wait for a light, drive in the opposite direction and find another jug handle to return. With only minutes to the start of my shift, I figured I would find out soon enough what was going on.

I arrived at the hospital, put my bags down, hung up my coat, and proceeded to receive sign-out from the dayshift doctor. After receiving report, I asked if the department had been alerted via HASTE for any inbound ambulances. I explained that there was a unit along the road a mile or two back with a MICU unit behind it for a least twenty minutes. At that moment, the squad rolled through the door. An approximately 60 year old was sitting upright on the stretcher, apparently quiet comfortable, wearing a 100% non-rebreather mask, smiling, and looking around. I asked if this was the same unit stopped on the state highway just up the road. The squad gave report of the various treatments and interventions initiated in field curbside along the highway.

Southern New Jersey has a very unique two tier EMS system which, after fifteen years, I am still getting use to it. It is predominantly a volunteer BLS system with ALS being provided by “chase-units”, consisting of Ford Explorers. The ALS units have no transport capability. Typically, the medics would climb aboard the BLS ambulance and provide higher level of care when needed or provide such on scene. Unfortunately, this system has lead to several issues, including the one addressed above.

The opening vignette, in my experience, is not at all unique. Prolonged transports from nursing homes only two or three miles down the road from one of the hospitals I work at for respiratory and cardiac arrests or from neighboring residential developments is not uncommon. There is a very strong motivation to provide advanced life support on-scene care despite the close proximity of a fully staffed Emergency Department. The concept of “scoop and run” by BLS units when close proximity to hospital care is at hand is often mistakenly misplaced for delayed scene times to await the arrival of ALS.

Another product of the two-tier system in New Jersey is a dangerous race of emergency vehicles and civilians in a long, “vehicular parade” to the hospital. The ambulance is followed by the paramedic chase unit, which is often followed or lead by a police car or two. Racing up the rear is usually family in their car despite being told not to try to follow the ambulance to the hospital. Other drivers, when hearing the sirens, usually only expect a single emergency vehicle. Two vehicles, especially if driving fairly tightly behind one another, can easily be unanticipated by motorists. With families trying to keep up with “the parade,” the potential for additional injuries is very real.

With state economics being what they are, funding to advance New Jersey volunteer crews to having ALS level of care is limited. The ideal would be to bring all squads up to the capacity of having a medic available for all runs if needed. Fewer rescue vehicles on the road would have the financial benefits of lower costs in equipment, fuel, and insurance for cash strapped municipalities. This system has been proven to work in New York State for decades. Nassau and Suffolk Counties in New York provide financing to train their volunteers to ALS level of care and limit the number of vehicles on the road for any individual call. Prolonged scene times are a rarity. Meanwhile, New Jersey has not managed to learn from it’s sister states how to manage within the constraints of finances to advance its volunteer EMS system and limit public risk.

I suspect the current system in New Jersey, with the paramedic chase units, represents a product of local politics, limited funding, billable ALS care by these chase units, combined with a hold over from when New Jersey was predominantly farmland with long distances between medical facilities. Southern New Jersey is increasingly not rural. As such, the current system is only adding to the financial costs to townships.

I invite others who read this blog to discuss their volunteer systems. Specifically, how do your systems manage to keep the public safe, provide ALS care, while dealing with the economic austerity affecting all municipalities today?

Comments from paramedics I work within this system are pending. At their request, I will post their thoughts regarding this blog’s subject matter anonymously and without editing.

ADDENDUM: All comments received have been posted provided objectionable language was not included. I have made every attempt to answer as many of the comments posted as I can.

I have become superstitious regarding compliments at work. Being an ED physician, “thank-yous” are certainly few and far between. Most of the time if someone approaches me from an administrative position or from another department with the opening line “do you have a minute?” or “do you remember that case?” my defenses go up immediately. Other ED physicians I have spoken to say they have the same reflex. It is rarely good news. Emergency Medicine is like being a race car driver. You are on a high-speed track and will eventually be stuck in the pit or hit the wall. Complaints and patient care issues are inevitable when facilitating care of a high volume of patients, usually under highly stressful conditions, often fatigued, while handling a wide range of patient acuity. So, I was ecstatic this past week when an administrator provided a back handed compliment. He stated that he had recently been contending with patient complaints in regards to the care provided by my colleagues and added that it had been a seemingly long time since anyone complained at all

about me. I should have known at that point in the conversation that I was a doomed!

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The shift started simply enough. The full moon outside should have been my additional warning. I had gone to my computer station, cleared out charts that needed to be completed, and printed up the nurse’s sheet for the first patient of my shift. As I was standing at my computer terminal, to my left I overheard the voice of a very animated woman conversing across the desk to a nurse. I printed up the nurse’s sheet for the first patient of my shift, assured that by the time I came back she would be gone. When I returned to my work area, I noticed the increasingly boisterous woman still in the same spot, sandwiched between the suture cart, the desk, and me, such that she was essentially on top of me. In an attempt to be polite, I let her finish her discussion for several generous minutes. I attempted to focus on my documentation and execute a few orders. I found it increasingly difficult to concentrate with this woman’s voice echoing from such a close distance. I finally turned to her and cordially explained that I would appreciate it if she continued her conversation a few feet down at the other end of the desk. She suddenly lashed out at me. “You are rude and inconsiderate!” “This is the worst hospital I have ever been at!” I tried to explain that this was my work area and explained I had to protect the patient data I was working with as required by law. She would hear nothing of it. I, on the other-hand got to “hear” all of “it” from the nursing supervisor twelve hours later! Apparently, the woman in question later contacted the offices of nursing administration to complain. The woman made it clear to the supervisor that she felt that I made the presumption that she was “white trash,” as she stated “because I didn’t have time to do my hair!” Not only that, but this woman actually recommended that I be slapped for making her feel that way. -And this was just complaint number one of the evening.

I wish I could say that my night improved much after that. The shift consisted of multiple patients brought in by police in handcuffs, crisis patients needing immediate psychiatric intervention, with several being exceptionally violent. I let the few less complex patients linger in the fast track area just to stabilize the escalating psych patients and appropriately manage those that were medically unstable. My plan was to subsequently move on to see some of the non acute patients in fast track.

I prepared to see a young woman with back pain and printed the nurse’s note. Figuring this would be an easy case, I quickly reviewed the triage information. Vitals all looked good and the narrative discussed how she walked from the waiting room down the hallway and into the room without difficulty. I then decided to take a quick look in our chart records to see if she had presented to the hospital in the past and if there were any further helpful details in her history regarding today’s complaint. Multiple presentations were present for dental pain and ankle pain, with prescriptions being provided every week or so for Vicodin and Percocet. I was suspicious but was going to give her the benefit of the doubt. I introduced myself from the doorway and immediately noticed an absolute discrepancy in her movement as compared to the triage note. She was ambulating with overt difficulty to such a degree that she could have doubled as a female version of Lurch from the movie TheAddams Family. Her movements were all slow, exaggerated, with hesitating motions, wincing and moaning. I obtain her complaint history and performed the physical examination. Subsequently I explained I wanted to get a few tests. I reassured her that based on the lack of risk factors for bony pathology, I expected the result would be a negative workup and most likely the diagnosis of lumbar strain. I added that we could most likely manage her well with some muscle relaxants and anti-inflammatories until she could she her doctor the next day.

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“I’ve tried those, and they don’t work,” she responded.

I offered her a generous IM dose of Toradol, explained it’s benefits, and recommended subsequent doses of muscle relaxants as well. She scoffed at my suggested plan of care.

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“You can see your primary doctor in the morning for further workup if we find no significant pathology tonight.”

“Can’t you give me anything stronger?” She asked.

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I explained my concerns for the freqeuncyof presentationsover the last several weeks, including multiple prescriptions for narcotics. I impressed once again that the discharge plan with Toradol would be effective and her primary doctor’s office could proceed with further management the next morning. The next few minutes consisted of the patient trying to convince me that my plan of care would not work because every medication I recommend was not strong enough. I finally had to excuse myself and proceed to other patients.

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A few hours passed and the x-ray order column never lit up as completed on the computer terminal for this patient. I wondered what had happened.

The nurse’s narrative said it all. “The patient refused the x-rays and left.” Furthermore, I was rude and called her a drug addict! While I did express concerns regarding the frequency that she had presented and received narcotics, the words “drug addict” never were uttered. Fortunately, during the patient’s stay she did provide a urine specimen for a drug screen. As I reviewed the result, I noticed that the patient was positive for opiates despite her claim that she was not taking any medication at triage. Do I believe I said anything in an even remotely rude manner? No. However, I then imagined yet another complaint for me to address with administration on the horizon.

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Things continued along the same vein for most of the evening. It was as if the forces of darkness were out to squash what good graces I had left with that mighty administrative complement.

Several patients who were regulars with psychiatric histories were “holds” in the department. The nurses were approaching me with requests for pain medications for several of these patients. At one point, without my mentioning a patient’s name, I verbalized at the work station to a nurse how I didn’t want to write for any pain medications for one particular patient as I wanted a chance to reassess her. I explained without mention of identifiers how this particular patient is frequently in the ED for various complaints and has multiple psychiatric issues. For whatever reason, I immediately afterwards seized the opportunity to show a newly hired nurse nearby how to pull up old records on our chart documentation program. I proceeded to show her without verbally mentioning any names or identifiers, how to pull up old records using a patient for which she was the primary nurse. Several minutes later, this same nurse approached me a few minutes later stating “You know, that lady in room K thinks you were talking about her! I apologized to her for you!”

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Great! I new I was in trouble.

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I reviewed the nurse’s notes and scanned the last several presentations. Sure enough, this woman had a psychiatric history as well as a substance abuse history.

Entering room K, the patient laid into me. “I have had a problem but it is taken care of!” I explained that I had not been speaking about her and she overheard a partial conversation not related to her at all.

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“Miss, I don’t think I have ever seen you before. I only now accessed what is documented in your old records.”

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I further explained that, as such, there was no way I therefore could have been referring to her. At the time, she seemed satisfied. Care was rendered appropriately. Nevertheless – a complaint was filed. While only a conversation was held without any identifiers at normal voice modulation at a designated work area, administration was alerted to a HIPAA violation complaint.

Lovely.

So there you have it…. I’ve become superstitious.

While I have had a black cat for years, along with a house number that happens to be 13, I never gave credence to superstition in the past. For now on, if I dare ever receive an administrative complement again I am going to immediately see if I can switch shifts with someone. Clearly such a happening is a sign for an ER physician that the forces of darkness are out to get him!

]]>http://www.theemsblog.com/2011/02/03/204/feed/5Hiding In The Nursing Loungehttp://www.theemsblog.com/2011/01/19/hiding-in-the-nurses-lounge/
http://www.theemsblog.com/2011/01/19/hiding-in-the-nurses-lounge/#commentsWed, 19 Jan 2011 12:35:56 +0000http://theemsblog.com/?p=210Recently my feathers became ruffled when my nursing staff shared with me that two EMT students decided to sleep in the nursing lounge rather than to introduce themselves and “dive right in.” Despite my nurses trying to “protect” these kids, I insisted on getting details and calling the EMT instructor to make sure hell was raised in class. I requested that these students return to perform their observation time all over again.

The two nurses who shared with me the events of that day are angels. Both were feeling incredibly guilty over “ratting out” these two kids. They saw my anger upon my hearing about the total disregard for learning that was displayed. “They aren’t learning to be fry cooks – they will be responsible for peoples lives!” I explained to my nurses that the observation time provided to these students to see what the Emergency Department staff actually does is crucial. The students need to be aware of what information we need, how we need patient histories presented, and how EMTs and Paramedics are our “eyes and ears” in the field. The rotation is more than just about “watching,” it is about honing skills and gathering a feeling of what processes proceed upon their bringing the patients through our sliding glass doors.

Many EMTs that I have seen over the recent years lack effective communication skills. The ability to communicate pertinent information in a concise and efficient manner is paramount. In no other hospital environment does rapid transmission of data in an effective matter hold such a high priority. Did the child have access to medications before he arrested? Was the accident victim’s car displaying a spidered windshield? How long ago was it that the stroke victim was last seen acting normally by his family? There have been several occasions where I personally feel like pulling my hair out trying to tease this data out of the rescue personnel bringing in patients.

I believe the solution to the effective data transmission problem is two pronged. First, the minimal observation time in the Emergency Department needs to be extended to more than the minimum of ten hours with emphasis on patient presentations. A rolling four-week rotation might make more logical sense, with students actively following a physician, physician-assistant, and nurse. Secondly, minimal standards in language skills and public speaking should also be a requirement. Testing should be mandatory to assure these skills are present prior to be entered into an EMT program. Failure to meet these standards represents a disservice to the EMT student and to the public for which they are training to serve.

ADDENDUM:

I have created a lot of conversation/controversy with this piece as can be viewed in the comments. There seems to be some general themes which I would like to share based on the responses.

First off, I wish to apologies to anyone who I offended with this blog post. The intent was never to be insulting, but rather to start a conversation regarding the issue of effective patient care reporting and student education. I strongly feel that effective public speaking and communicating patient reports in an efficient manner is a paramount skill needed in the Emergency Medicine/EMS arena. As such, all comments which were submitted, both positive and negative, have been posted as of my logging in today on 1-19-11 at 1900 EST

For clarification to those who don’t follow my blog and expressed concern that I have no in-field experience, I was a New York City EMS provider. I was initially stationed out of Bedford-Stuyvesant, (Woodhall Hospital) and subsequently out of Queens General Hospital (worked a tactical unit) . I have worked in the field in EMS for years (both public and private sector), volunteer my time as a proctor for EMS examinations, actively teach EMT programs, and was a volunteer firefighter. I have worked both the suburban and urban arenas. I started this blog as an effort to promote positive change and as well as advancement of Emergency Medical Services.

Of further note, a substantial number of the nursing staff with whom I work are EMTs, flight nurses, and paramedics themselves. We all put in a great deal of effort whenever an EMT student rotates through our ER to teach. I have the students follow me on a rotating basis listening to heart sounds, breath sounds, and perform examinations. We actively discuss and teach pathology . The nurses help the students splint, take vitals, and assist in care. We take our roles with these students very seriously. We aren’t mandated to do this. We do this because of genuine concern for the education of these students and our patients. In this context, I believe it becomes obvious why I was so angry regarding these two individuals who were found sleeping in the lounge.

To address some key points which were made:

1) There are communication issues on both the hospital and prehospital side of EMS care. As was noted in one of the responses listed below, most ED personnel are overworked and there are incidences where EMS personnel are ignored. I agree that ignoring our infield colleagues is absolutely wrong. A vicious circle, however, ensues. ED staff who are met with ineffectively communicated reports tune out the prehospital provider. This, in-turn, leads to the prehospital care provider feeling unappreciated. A negative feedback loop is created.

Since this blog is intended to discuss issues in prehospital/EMS care and look for solutions, my suggestion is that if you are dealing with a hospital environment where you or your staff are being ignored, discuss this with the ED nurse manager or ED director. Find out how to correct this problem! Offer ride-alongs. Offer teaching in turn. Meanwhile, the initial premise which I was trying to convey, being that of assuring exposure to effective patient reporting to the EMT student, might be augmented by extended ED rotations and education in honing communication skills.

2) The issue of pay and salary was raised by several individuals. I agree that in many areas EMS isn’t even considered an essential service. This is absolutely wrong and does need to be changed. I have addressed this concern in a prior blog. However, pay and the responsibility inherent to accepting a job where people’s lives are involved are two separate issues. There are towns where police are paid horribly and their lives are constantly at risk. Should they, therefore not protect the public? Since the blog addressed two of my students who were caught sleeping in the nurses lounge, should police cadets who know they will be serving in poorly paid dangerous cities not bother to learn? Obviously not.

3) Someone raised the issue of difficult staffing in volunteer squads. This is a tough topic. I would argue that maintaining a standard would be of greater value than pure staffing.

4) Another individual raised the issue of how, as a medical student, he routinely has to present cases as part of his training. He referenced how little didactic coverage is included in the current EMT course work. He makes a valid point! I would argue that this should be addressed in EMT core curriculum

5) For clarification, my statement regarding the need for effective communication skills does not imply being a native English speaker. Being able to relay a concise detailed report with pertinent information is my concern.

I truly like the response from paramedic George

“It’s a skill that communication should be simultaneously efficient and effective. There are only benefits in seeking better cooperation between ER nurses and EMS. And between SNF nurses and EMS. Between any and all healthcare providers transferring care or working as a team. It’s everyone’s duty to keep improving their skills, for supervisors to support and encourage development of providers’ skills, including communication skills. Don’t wait until there’s a problem involving a patient outcome to recognize this. Thank you all.”.

]]>http://www.theemsblog.com/2011/01/19/hiding-in-the-nurses-lounge/feed/54EMS System in NJhttp://www.theemsblog.com/2011/01/10/ems-system-in-nj/
http://www.theemsblog.com/2011/01/10/ems-system-in-nj/#commentsMon, 10 Jan 2011 19:26:50 +0000http://theemsblog.com/?p=196With permission – the following is an email from a paramedic with whom I have a great deal of respect for. He and I have had conversations regarding the state of EMS in New Jersey. Fear of reprisals from his employer is the reason his identity having been removed from this email. This Paramedic has also discussed the number of other New Jersey paramedics with similar frustrations. We have also discussed the issue of this individual coming on-board under an alias and using this blog as a conduit and public forum to help institute change to a very broken system.

This paramedic’s email follows:

Hey Jordan,

I thoroughly enjoyed reading your blog. I can certainly understand your frustrations with the system since you are a direct recipient of the final product as the squads roll into the ED each and every day. I myself am appalled by the way things are run, particularly in clinical oversight, education length and quality, as well as policies and procedures. Unfortuneatly, there is nothing, you, I, nor anyone at the Department of Health level can actually change, due to the restrictive legislature that gives us the authority to operate is antiquated and limiting in it’s wording, rather than being enabling and progressive.

What really blows my mind is that the system we currently operate in does not mandate any minimum standards for providers (mainly BLS, as ALS is in my opinion OVER regulated), does not require an ambulance to be licensed by the Department of Health nor meet any minimum standards, nor mandate minimum response times. Better yet, EMS in New Jersey isn’t even considered an essential service like police, fire, and municipal services are. It’s simply, sickening.

Like I told you, there is a bill that we are trying to pass which will overhaul the EMS system in NJ, and change A LOT of things. This is in response from a outside consulting company that spent quite some time in the state, auditing the way our EMS system is running, and what we can do to improve it. I have included a copy of the report as well as a copy of the bill, which is a response to the system report in this e-mail. In a nutshell, the report stated that the NJ EMS system in a “state of near collapse.”

The main opponent to this overhaul bill is the New Jersey State First Aid Council, which we so affectionately call “The First Grade Council.” I am thoroughly convinced that they are the sole reason EMS in NJ is so backwards and antiquated. If they are allowed to maintain any type political or lobbying power, there is no way we can progress into the 20th century here, let alone the 21st century. They oppose a two EMT minimum standard, increasing the amount of time an EMT class takes to complete (we’re trying to comply with the new National Scope of Practice with this bill), allowing the Dept. of Health full authority over the operation of an ambulance, as well as many other things. Too many to list actually. However, if this passes, the Council will basically be rendered powerless, and we can finally move on, without them.

Here is a link to the TriData report that was done on the EMS system a few years back. Verrrry interesting.

]]>http://www.theemsblog.com/2011/01/10/ems-system-in-nj/feed/11Time for Intelligence in Implementing EMShttp://www.theemsblog.com/2011/01/01/time-for-intelligence-in-implementing-ems/
http://www.theemsblog.com/2011/01/01/time-for-intelligence-in-implementing-ems/#commentsSat, 01 Jan 2011 15:05:08 +0000http://theemsblog.com/?p=178During the recent snowstorm, the governor of New Jersey declared a state of Emergency closing all roads to nonemergency vehicles. As luck would have it, I was on shift at one of the hospitals where I work. My colleague received a call from a local EMS squad. A stabbing was inbound. The EMT on the phone relayed no valuable details except she didn’t care how bad the wounds were. While she hadn’t even arrived at the scene yet, with the weather being bad as it was, she was coming to us “no matter what”. The hospital where I worked that day is a small community hospital without in house surgery, no trauma team, and a physician staff for the entire hospital that evening which probably consisted of two ER physicians, an anesthesiologist, and two hospitalists. Several miles down the road is a larger hospital with significantly more resources. While the above vignette alone can generate significant discussion, this is only one item in my ire over local prehospital care

The literature is full of studies how the Europeans will actually divert ambulances with acute MI patients from local hospitals to those with catheterization labs. Two Emergency Physicians whom I enjoy listening to on their Emergency Medicine literature review CDs, Doctors Jerry Hoffman and Richard Buckata, not long ago discussed how patients having acute coronary events in the driveways of European hospitals would be told not to unload their patients, travel to the next facility with the appropriate interventional resources, and how much better the outcomes are for these patients. This is certainly not the practice in the region where I work.

Where is the logic of a pediatrician sharing in clear language her high clinical suspicion for acute appendicitis in a child with an EMS team and then those same EMTs making the decision to bring that child to a hospital without pediatrics or pediatric surgery? This defies any logic. What is accomplished? Delay in definitive care, added unnecessary expensive, additional transport time, and psychological trauma to the child and her family.

At another hospital where I also work, local EMS squads historically will ignore bypass requests. Responses by EMTs to questions regarding their rational for ignoring critical care divert and bypass requests as the nurses share with me that they have run out of pumps and cardiac monitors, “The patient insists on coming here”. Other responses I have received from these same EMTS and medics as they bypassed two and three hospitals (incidentally, all within the same hospital system with the same physician groups) on their 25 mile trek to this particular hospital are “ divert is a courtesy request only,” and, this is my personal favorite, “ we don’t want to be accused of kidnapping patients”. Kidnapping patients? ! I understand completely that while on divert a hospital cannot expect all EMS inflow to stop and critical care patients will still arrive. Bypassing multiple hospitals that aren’t overwhelmed due to a family request is endangering ALL patients in that ER – including the one being “Kidnapped!” When someone is calling 911, they are calling for a rescue service and not a taxi ride. Of course, I should share that this problem has been partially “solved.” Many hospital administrators regionally are refusing to allow the ED Attending physicians to warn EMS squads of strained resources by forbidding bypass requests.

I have been in the streets myself for many years working for EMS systems. I helped pay my way through school working in Brooklyn and Queens. I am very proud of my background with New York City EMS. I am currently actively involved in EMS education. Hence, I don’t believe anyone can say I do not know what I am talking about in regards to “being in the field.” Under most circumstances, when I worked in New York, you were taken to the closest hospital. No “special trips” taking a rescue unit out of it’s assigned region because the family likes the décor at a different hospital better. It was simple. Burns? Burn unit. Trauma? The nearest trauma hospital. If the local hospital in our “PAR” was over whelmed, we tried to “share the burden” with the next closest facility

Going back to that snowstorm shift and the trauma patient, the blade missed the femoral artery on CT angiography. The child who had been taken past a facility with pediatrics by local EMS had no difficulties in being transferred to another pediatric surgical hospital by ground three hours later after I had back all the studies to make a convincing argument to the surgeon at this other hospital to accept transfer. CT confirmed acute appendicitis. As far as the local roads were concerned that night, while I am sure some portions of New Jersey were hit hard, I enjoyed listening to Jimmy Buffett on the radio as I took my time driving the some odd twenty-five miles home in my car without any difficulties.